P - 84530���� �� �� ��� �� ��� �� ��� �� ��� �� ��� �� ��� ii i�i i i��i
REGIUEST FOR ELECTRICA� INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
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Home Duplex Apt. Bldg. Other: C �� y New Addn
Commercial Industrial Farm � -E3�C.� Remod Re air
Air Cond. Htg. Equip. Water Htr. Load Mgmt. Olther:
D er Ran e Elec. Heat Tem . Service L/�/l7��S t�' Q��` �^%�
"k' above the work covered by fhis request. Enter remarks in this space and on the back of the whitP copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Ofher Fee � $ervice Enh�ance Size Fee # Circvih/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to l00 Amps ,Q'Q
Street Ltg./Traffic Sig. Above 200 Amps Above 10 Amps '
Transformer/Generator INSPECTOfi'SUSEONLY TOTAL / �
$ign/Outline Ltg. Xfmr. �y,y�[ �-1 1 /• s
Alarm/Remote Control
$w'imming Pool
I hereb certi fhat I ins ecied the eledrital insMllation described herein on the dafas stated
I��i9ation Boo Rough-In Dotc
Speciallnspection � "—" ��
Final �.( pa
Investigative Fee �' ,—'��„
THIS INSTALLATION MAY BE ORDERED DISCONNE D IF NOT COMPLETED WITHIN 18 MONTHS.
2 9 9— 3 6 0� OFFICE USE ONLY This request void 18 months from validation date printed in this box.
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PLEASE PRINT OR TYPE `
Request D��/� � Rough-in inspection required2 Yes � No Inspedion Ofher Than Rough-In: � Ready Now Will Call
(You musf call the inspecfor when reody) Date Reody:
I, ❑ licensed contrador � owner hereby request inspection of the above electrical work at:
Job Address (Sfreet, Boz, or Rout No.) City Zip Code
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$edion No. Townshi Name or o. Ran e No. Fire No. Coun
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Occupa� � �� �� ��� Pho������ �� ^I
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Power Supplier Address
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Elechical Conhacior (Company Name) ontrador License No. Master Lic. No. (Plant Elecf. Only)
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Mailing Address (Contra Owner Performing Installafion)
Authorized ' re onfrador or wner Pe o ing Installafion) � � Phone No.
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EB-OOOOtA-10 6/95 STATE BOARD COPY- SEE INSTRUCTIONS ON BACKOF YELLOW COPY